Postop Chest Tube Strategy Still Murky

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Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.

In this randomized study, after lung resection, the use of suction or water seal drainage were not different in terms of prevention of prolonged air leaks.

LOS ANGELES -- After lung surgery, suction may not prevent prolonged air leaks better than the water seal method, interim results from a randomized trial showed.

Persistent air leaks on day 7 after surgery occurred in a similar proportion of patients with both interventions, 10% with suction versus 14% with water seal (P=0.20), Francesco Leo, MD, PhD, of the Istituto Nazionale dei Tumori in Milan, Italy, and colleagues reported in the AirINTrial.

There was a borderline advantage to suction in anatomical resection, with 10% having an air leak at day 7 versus 17% with water seal (P=0.05), Leo noted at a late-breaking presentation here at the Society of Thoracic Surgeons meeting.

While that subgroup may be the most important one for tackling air leaks, several aspects of the trial limit the clinical utility of the findings, cautioned John Howington, MD, of NorthShore University Health System in Evanston, Ill.

"Prolonged air leak is really only a problem when you do an anatomic resection, so a lot of patients included in the trial aren't relevant for managing air leaks," he told MedPage Today in an interview.

That would impact power of the trial to show a difference between managment strategies, if one exists.

The Italian trial randomized patients to suction at 15 cmH2O negative pressure for the first 3 postoperative days or the first day followed by water seal to day 3, after which drains were removed or connected to a Heimlich device, followed by discharge on day 5.

By contrast, "in most current U.S. series the chest tubes would be out and the patient would be home in 3 days," Howington noted.

After "typically an initial period usually just overnight of suction and then water seal in the U.S., usually within a day or two there's no air leak and the tube comes out and the patient goes home," he explained. "It would be hard to apply this trial to U.S. practices."

The issue is still open, though, Leo argued. He pointed to the limited number of often underpowered trials and a recent meta-analysis that came up neutral.

His group randomized all adult candidates for lung resection, except pneumonectomy, with stratification by type of resection at a single center. The interim analysis occurred after enrollment of the first 500 of a planned 1,600 patients.

Among them, 26 patients overall were discharged with a drain at post-operative day 7, while 33 remained hospitalized with a drain due to persistent air leak.

While the treatment groups didn't differ significantly for that primary endpoint, pleural complications tended to be less common in the suction group (14% versus 22%, P=0.01), particularly pneumothorax (4 versus 12 cases, P=0.04).

Leo cautioned the audience about the small numbers for pneumothorax, recommending that they wait for the "more robust result" from the full sample size.

Subgroup analysis in the suction group suggested that prolonged air leak was more common the higher the air flow on postoperative day 2, rising from 0% among those with low flow under 200 ml/min to 27% among those in the top quartile at more than 800 ml/min.

The highest rate (60%) was in those with high pressure and negative maximal intrapleural pressure on day 2.

But the rate was also high (40%) in the intermediate-flow patients who failed to reach negative pressures and instead had maximal intrapleural pressure near zero, "suggesting that there is a certain level of negative intrapleural pressure that favors air leak stop."

"Data on air flow and pressures may be helpful in defining the risk of prolonged air leak, but its usefulness needs further confirmation," Leo added.

None of the risk factors for pleural leak differed between groups, but there was crossover of 6% in the suction group and 11% in the water seal group that wasn't excluded from the intent-to-treat analysis. Surgeons were allowed to use glues at their discretion.

The researchers reported having no conflicts of interest to disclose.

Howington reported being on the thoracic advisory board for Ethicon Endo-Surgery.

Reviewed by Zalman S. Agus, MD Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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